Under the supervision of the Director of HIM, the HIM Coder is responsible for coding and abstracting medical records, including all diagnoses for inpatient and partial hospitalization medical records, using the International Classification of Diseases (ICD-10-CM), and entering coded information into the MIRA computer system. Performs related work as required. This is a 100% on-site position. Remote work or hybrid schedules are not available for this role.
Education: Graduation from a HIM program preferredhigh school or equivalent, with knowledge of general office skills required. Experience: RHIA or R.H.I.T required with 1 year coding experience or CCA with 2 years coding experience, or CCS or CC-P with 1 year coding experience, and at least one year of experience in a HIM department. Additional Requirements: Knowledge of medical terminology, anatomy, physiology, and ICD-10-CM classification system is required. Computer knowledge is helpful. Must be able to use a computer keyboard, read medical reports, and sit for long periods of time.
Ability to work with a high degree of precision, paying attention to detail in order to achieve the high levels of accuracy required. Ability to adhere to ethical principles relating to quality, truth, and accuracy in work performance and productivity. Ability to organize, collect and classify diagnostic information for hospital reimbursement purposes. Thorough knowledge of medical terminology. Knowledge of the International Classification of Diseases (ICD-10-CM) codes; knowledge of DSM V Diagnostic Manual of Mental Disorders. Ability to communicate effectively both orally and in writing. Ability to be thorough. Possesses sound judgment; discretion; and initiative. Ability to organize and set workload priorities to meet deadlines. Thorough understanding of the content of the medical record as well as clinical knowledge including extensive training in anatomy, physiology, pharmacology, and clinical disease process. Ability to assess the medical record content and highlight shortcomings to management. Ability to maintain ICD-10-CM coding books to make sure they are updated to the current version being used. Ability to assist with the education of clinical staff with regard to ICD-10-CM and documentation requirements. Ability to liaison with computing and finance staff. Ability to adhere to safety policies and procedures. Ability to work as a team player. Ability to demonstrate resourcefulness, patience and dedication. Ability to accept direction and adhere to policies and procedures. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric). Ability to work in a fast-paced environment. Ability to react calmly and effectively in emergency situations. Ability to continually update skills and knowledge.
Ability to sit for long periods, up to 8 hours. Ability to use both hands in fine manipulation of small tools (e.g., copier, computer keyboard, telephone). Ability to push and pull up to 10 lbs. (file cabinet drawers, computer paper boxes). Ability to see well enough to read handwritten and typewritten material. Ability to stoop, kneel, and bend daily to retrieve files from bottom shelves. Ability to move flexibly is required in filing and retrieving medical records. Ability to reach, turn, and twist above and below the waist daily to retrieve files from top shelves to get office supplies from upper shelves in supply closet. Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical for business office atmosphere. Attend all mandatory facility in-services and staff development activities as scheduled.
Computer and various software programs. Copy machine. Policies, procedures, plans and program manuals. ICD-10-CM, DSM V and related reference books.